AB365-SSA3,28,2322 3. The copayments, deductibles, and coinsurance are not actuarially equivalent
23to comprehensive individual plans and would create undue financial hardship.
AB365-SSA3,28,2524 4. It is inconsistent with the purpose of providing health care coverage to those
25unable to obtain coverage in the private market.
AB365-SSA3,82
1Section 82. 631.36 (7) (c) of the statutes is created to read:
AB365-SSA3,29,42 631.36 (7) (c) Notice of cancellation or nonrenewal required under sub. (2) (b)
3or (4) is not effective unless the notice contains the notice required under s. 632.784,
4if applicable.
AB365-SSA3,83 5Section 83. 632.7495 (4) (c) of the statutes is amended to read:
AB365-SSA3,29,136 632.7495 (4) (c) The coverage term aggregated with all consecutive periods of
7the insurer's coverage of the insured by individual health benefit plan coverage not
8required to be renewed under this subsection does not exceed 18 months. For
9purposes of this paragraph, coverage periods are consecutive if there are no more
10than 63 days between the coverage periods. This paragraph does not apply if
11provisions of the federal Patient Protection and Affordable Care Act, P.L. 111-148,
12under 42 USC 300gg to 300gg-4 are no longer enforceable or no longer preempt state
13law relating to individual health insurance policies.
AB365-SSA3,84 14Section 84. 632.784 of the statutes is created to read:
AB365-SSA3,29,21 15632.784 Notice of Health Insurance Risk-Sharing Plan. (1) If an insurer
16issues one or more of the following or takes any other action based wholly or partially
17on medical underwriting considerations which is likely to render any person eligible
18under s. 656.12 for coverage under ch. 656, the insurer shall notify all persons
19affected of the existence of the mandatory health insurance risk-sharing plan under
20ch. 656, as well as the eligibility requirements and method of applying for coverage
21under the plan:
AB365-SSA3,29,2222 (a) A notice of rejection or cancellation of coverage.
AB365-SSA3,30,223 (b) A notice of reduction or limitation of coverage, including restrictive riders,
24if the effect of the reduction or limitation is to substantially reduce coverage

1compared to the coverage available to a person considered a standard risk for the
2type of coverage provided by the plan.
AB365-SSA3,30,53 (c) A notice of increase in premium exceeding the premium then in effect for
4the insured person by 50 percent or more, unless the increase applies to substantially
5all of the insurer's health insurance policies then in effect.
AB365-SSA3,30,86 (d) A notice of premium for a policy not yet in effect which exceeds the premium
7applicable to a person considered a standard risk by 50 percent or more for the types
8of coverage provided by the plan.
AB365-SSA3,30,10 9(2) Any notice issued under sub. (1) shall also state the reasons for the rejection,
10termination, cancellation, or imposition of underwriting restrictions.
AB365-SSA3,85 11Section 85. 646.01 (1) (a) 2. k. of the statutes is amended to read:
AB365-SSA3,30,1212 646.01 (1) (a) 2. k. Risk-sharing plans under ch. chs. 619 and 656.
AB365-SSA3,86 13Section 86 . Chapter 656 of the statutes is created to read:
AB365-SSA3,30,1514 Chapter 656
15 Health insurance risk-sharing plans
AB365-SSA3,30,1716 SUBCHAPTER I
17 general provisions
AB365-SSA3,30,18 18656.01 Definitions. In this chapter:
AB365-SSA3,30,19 19(1) “Authority” means the Health Insurance Risk-Sharing Plan Authority.
AB365-SSA3,30,20 20(2) “Board” means the board of directors of the authority.
AB365-SSA3,30,21 21(3) “Church plan” has the meaning given in 29 USC 1002 (33).
AB365-SSA3,30,22 22(4) “Commissioner” means the commissioner of insurance.
AB365-SSA3,30,23 23(5) “Creditable coverage” has the meaning given in s. 632.745 (4).
AB365-SSA3,31,3
1(6) “Eligible person” means a person who is certified as eligible under s. 656.12
2(1), whether or not the person is legally responsible for the payment of medical
3expenses incurred on the person's behalf.
AB365-SSA3,31,4 4(7) “Federal continuation provision” has the meaning given in s. 632.745 (8).
AB365-SSA3,31,7 5(8) “Federal governmental plan” means a benefit program established or
6maintained for its employees by the government of the United States or by any
7agency or instrumentality of the government of the United States.
AB365-SSA3,31,9 8(9) “Fund” means the Health Insurance Risk-Sharing Plan fund under s.
9656.10 (2).
AB365-SSA3,31,10 10(10) “Governmental plan” has the meaning given under 29 USC 1002 (32).
AB365-SSA3,31,11 11(11) “Group health plan” has the meaning given in s. 632.745 (10).
AB365-SSA3,31,13 12(12) “Health care coverage revenue” means any of the following, but does not
13include payments to health maintenance organizations under s. 49.45 (59) (a):
AB365-SSA3,31,1414 (a) Premiums received for health care coverage.
AB365-SSA3,31,1515 (b) Subscriber contract charges received for health care coverage.
AB365-SSA3,31,1716 (c) Health maintenance organization, limited service health organization, or
17preferred provider plan charges received for health care coverage.
AB365-SSA3,31,1918 (d) The sum of benefits paid and administrative costs incurred for health care
19coverage under a medical reimbursement plan.
AB365-SSA3,31,25 20(13) “Health insurance” means surgical, medical, hospital, major medical, and
21other health service coverage provided on an expense-incurred basis and fixed
22indemnity policies. “Health insurance” does not include ancillary coverage such as
23income continuation, short-term, accident only, credit insurance, automobile
24medical payment coverage, coverage issued as a supplement to liability coverage,
25loss of time, or accident benefits.
AB365-SSA3,32,1
1(14) “Health maintenance organization” has the meaning given in s. 609.01 (2).
AB365-SSA3,32,3 2(15) “HIV” means any strain of human immunodeficiency virus, which causes
3acquired immunodeficiency syndrome.
AB365-SSA3,32,4 4(16) “Insurance” has the meaning given in s. 600.03 (25).
AB365-SSA3,32,6 5(17) “Insurer” has the meaning given in s. 600.03 (27) and does not include a
6plan under ch. 613 which offers only dental care.
AB365-SSA3,32,8 7(18) “Limited service health organization” has the meaning given in s. 609.01
8(3).
AB365-SSA3,32,10 9(19) “Medical Assistance program” means the health care benefit program
10provided under subch. IV of ch. 49.
AB365-SSA3,32,11 11(20) “Policy” has the meaning given in s. 600.03 (35).
AB365-SSA3,32,16 12(21) “Preexisting condition exclusion” means, with respect to coverage, a
13limitation or exclusion of benefits relating to a condition of an individual that existed
14before the individual's date of enrollment for coverage, whether or not the individual
15received any medical advice or recommendation, diagnosis, care, or treatment
16related to the condition before that date.
AB365-SSA3,32,17 17(22) “Preferred provider plan” has the meaning given in s. 609.01 (4).
AB365-SSA3,32,18 18(23) “Premium” has the meaning given in s. 600.03 (38).
AB365-SSA3,32,22 19656.03 Applicability. This chapter applies only if provisions of the federal
20Patient Protection and Affordable Care Act, P.L. 111-148, under 42 USC 300gg to
21300gg-4 are no longer enforceable or no longer preempt state law relating to
22individual health insurance policies.
AB365-SSA3,33,2 23656.05 Immunity. No liability may be imposed on any of the following for an
24act or omission in the performance of any powers and duties under this chapter,

1unless the person asserting liability proves the act or omission constitutes willful
2misconduct:
AB365-SSA3,33,3 3(1) The authority, plan, or board.
AB365-SSA3,33,4 4(2) Any agent, employee, or director of the authority, plan, or board.
AB365-SSA3,33,5 5(3) Any participating insurer.
AB365-SSA3,33,6 6(4) The commissioner.
AB365-SSA3,33,7 7(5) Any of the commissioner's agents, employees, or representatives.
AB365-SSA3,33,108 SUBCHAPTER II
9 health insurance risk-sharing
10 plan provisions
AB365-SSA3,33,13 11656.10 Administration of plan. (1) Authority. The authority shall be
12responsible for the operation of the plan and, subject to ss. 656.43 (3) and 656.47, may
13enter into contracts for the plan's administration.
AB365-SSA3,33,16 14(2) Fund. (a) The authority shall pay the operating administrative expenses
15of the plan from the fund, which shall be outside the state treasury and which shall
16consist of all of the following:
AB365-SSA3,33,1717 1. Insurer assessments paid under s. 656.15.
AB365-SSA3,33,1818 2. Premiums paid by eligible persons.
AB365-SSA3,33,1919 3. Moneys received from the federal government as grants for high-risk pools.
AB365-SSA3,33,2020 4. The earnings resulting from investments under par. (b).
AB365-SSA3,33,2121 5. Any other moneys received by the authority.
AB365-SSA3,33,2322 (b) The authority controls assets of the fund, including investment of assets of
23the fund.
AB365-SSA3,33,2524 (c) Moneys in the fund may be expended only for the purposes specified in par.
25(a).
AB365-SSA3,34,5
1656.11 Rules relating to creditable coverage. The commissioner shall
2promulgate rules that specify how creditable coverage is to be aggregated for
3purposes of s. 656.12 (1) (c) 1. and that determine the creditable coverage to which
4s. 656.12 (1) (c) 2. and 4. applies. The rules shall comply with any applicable federal
5law regarding creditable coverage.
AB365-SSA3,34,8 6656.12 Eligibility determination. (1) Eligible persons. Except as provided
7in sub. (3) and subject to subs. (2) and (4), the authority shall certify as eligible a
8person who is a resident of this state and is any of the following:
AB365-SSA3,34,109(a) A person who is covered by the Medicare program under 42 USC 1395 et seq.
10because he or she is disabled under 42 USC 423.
AB365-SSA3,34,1211 (b) A person who submits evidence that he or she has a positive, validated HIV
12test result, as defined in s. 252.01 (8).
AB365-SSA3,34,1313 (c) A person for whom all of the following apply:
AB365-SSA3,34,1514 1. The aggregate of the individual's periods of creditable coverage is 18 months
15or more.
AB365-SSA3,34,1816 2. The individual's most recent period of creditable coverage was under a group
17health plan, governmental plan, federal governmental plan, church plan, or under
18any health insurance offered in connection with any of those plans.
AB365-SSA3,34,2219 3. The individual does not have creditable coverage and is not eligible for
20coverage under a group health plan; part A, B, or D of the Medicare program under
2142 USC 1395 et seq.; or a state plan under the Medicaid program under 42 USC 1396
22et seq.
AB365-SSA3,34,2523 4. The individual's most recent period of creditable coverage was not
24terminated for any reason related to fraud or intentional misrepresentation of
25material fact or a failure to pay premiums.
AB365-SSA3,35,3
15. If the individual was offered the option of continuation coverage under a
2federal continuation provision or similar state program, the individual elected the
3continuation coverage.
AB365-SSA3,35,44 6. The individual has exhausted any continuation coverage under subd. 5.
AB365-SSA3,35,85 (d) A person who receives and submits any of the following notices based wholly
6or partially on medical underwriting considerations within 9 months before making
7an application for coverage by the plan and issued by a person acting as an
8administrator, as defined in s. 633.01 (1):
AB365-SSA3,35,99 1. A notice of rejection of coverage from one or more insurers.
AB365-SSA3,35,1010 2. A notice of cancellation of coverage from one or more insurers.
AB365-SSA3,35,1411 3. A notice of reduction or limitation of coverage, including restrictive riders,
12from an insurer if the effect of the reduction or limitation is to substantially reduce
13coverage compared to the coverage available to a person considered a standard risk
14for the type of coverage provided by the plan.
AB365-SSA3,35,1715 4. A notice of increase in premium exceeding the premium then in effect for the
16insured person by 50 percent or more, unless the increase applies to substantially all
17of the insurer's health insurance policies then in effect.
AB365-SSA3,35,2018 5. A notice of premium for a policy not yet in effect from 2 or more insurers
19which exceeds the premium applicable to a person considered a standard risk by 50
20percent or more for the types of coverage provided by the plan.
AB365-SSA3,35,2521 (e) A person not otherwise eligible under this subsection who meets eligibility
22criteria set by the authority. The authority shall ensure that any expansion of
23eligibility is consistent with the purpose of the plan to provide health care coverage
24for those who are unable to obtain health insurance in the private market and does
25not endanger the solvency of the plan.
AB365-SSA3,36,6
1(2) Resident status. (a) For purposes of eligibility under sub. (1) (a), (b), (d),
2and (e), a resident is a person who has been legally domiciled in this state for a period
3of at least 3 months. Except for any of the following circumstances, legal domicile
4is established by living in this state and obtaining a Wisconsin motor vehicle
5operator's license, registering to vote in Wisconsin, or filing a Wisconsin income tax
6return:
AB365-SSA3,36,97 1. A child is legally domiciled in this state if the child lives in this state and if
8at least one of the child's parents or the child's guardian is legally domiciled in this
9state.
AB365-SSA3,36,1310 2. A person with a developmental disability or another disability that prevents
11him or her from obtaining a Wisconsin motor vehicle operator's license, registering
12to vote in Wisconsin, or filing a Wisconsin income tax return is legally domiciled in
13this state by living in this state.
AB365-SSA3,36,1514 (b) For purposes of eligibility under sub. (1) (c), a resident is a person who
15legally resides in this state.
AB365-SSA3,36,21 16(3) Exceptions to eligibility. (a) No person who is covered under the plan and
17who voluntarily terminates the coverage under the plan is again eligible for coverage
18unless 12 months have elapsed since the person's latest voluntary termination of
19coverage under the plan. This paragraph does not apply to a person who is eligible
20under sub. (1) (c) or who terminates coverage under the plan because he or she is
21eligible to receive benefits under the Medical Assistance program.
AB365-SSA3,36,2322 (b) No person on whose behalf the plan has paid out the lifetime limit under
23s. 656.20 (2) (a) or more is eligible for coverage under the plan.
AB365-SSA3,37,3
1(c) No person who is 65 years of age or older is eligible for coverage under the
2plan unless the person is eligible under sub. (1) (c) or the person has coverage under
3the plan on the date on which he or she attains the age of 65 years.
AB365-SSA3,37,94 (d) No person who is eligible for creditable coverage, other than those benefits
5specified in s. 632.745 (11) (b) 1. to 12. that are provided by an employer on a
6self-insured basis or through health insurance, is eligible for coverage under the
7plan. The board may specify, subject to approval of the commissioner, other types of
8coverage provided by an employer that do not render a person ineligible for coverage
9under the plan.
Loading...
Loading...